In the healthcare system, there are generally patients, providers, and payers. A patient is a person who comes to the provider for diagnoses or treatment of medical conditions. Providers include medical practitioners and professionals (such as dentists, nurse practitioners, physicians, and therapists) as well as medical service facilities (such as private offices, hospitals, and outpatient centers), medical service providers (such as pharmacies and laboratories) and other individuals or companies which provide medical diagnosis and treatment services. Payers are payment organizations which assist patients in paying for the diagnosis and treatment fees, and include privately owned health insurance companies, as well as publicly funded programs including Medicare, and Medicaid.
When a patient visits a provider for a diagnosis or treatment, the patient incurs a service fee. Depending on the patient's health insurance plan, the patient may have to pay a portion of the service fee to the provider, also known as a co-payment. The patient or the provider then fills out a medical insurance claim form and submits it to one or more payers to collect the rest of the service fee.
The payers and other organizations have standardized medical claim forms to help the payers and providers communicate with each other in a uniform manner. An exemplary standardized claim form is shown in U.S. Pat. No. 7,386,526, which is incorporated herein by reference. The sample claim form includes 85 fields for entry of information and codes. For instance, field 1 is used for entry of the provider name, address, and telephone number. Fields 12-16 are used for entry of the patient's personal information, such as name, address, birth date, and gender. Fields 67-81 are used for entry of codes corresponding to the diagnosis and procedure performed by the provider. Field 82 is used for entry of an identification code of the attending physician. Each doctor is identified by a physician identification code, rather than by their name, on the medical claim form. Typically, a third party or a manually created conversion table is used to convert between the identification code and the physician's name because identification codes for physicians are publicly available.
Instead of writing down on the claim form the complete diagnoses or procedures that were performed, the provider can utilize a code corresponding to the respective diagnosis and procedure. Diagnosis and procedure codes are standardized and established by healthcare industry standards groups, such as the National Uniform Billing Committee (NUBC), State Uniform Billing Committee (SUBC), American Medical Association (AMA), and Drug Enforcement Administration (DEA).
There are various diagnosis and procedure coding systems for different fields of medicine, services, and treatments. Each coding system contains thousands of unique diagnosis or procedure codes for providers to use in filling out the medical claim forms. One diagnosis coding system is the International Classification of Disease with Clinical Modifications, 9th Revision (ICD-9 CM, hereinafter “ICD-9”), developed by the World Health Organization. Payers and providers commonly use the ICD-9; codes on medical claim forms to describe diagnoses of symptoms, injuries, diseases, and medical conditions. For example, the ICD-9 code 414.0 would be typically recorded for patients who were diagnosed with the condition of Coronary Atherosclerosis. One procedure coding system is the Current Procedure Terminology (CPT) developed by the AMA. Payers and providers commonly use CPT codes to describe procedures or services that providers may perform on patients. These procedures and services are then subsequently reimbursed by the payer, such as an insurer. For example, on a medical claim form, CPT 31255 code indicates that a provider has performed a surgical nasal or sinus endoscopy on the patient. The DEA also developed a Healthcare Common Procedure Coding System (HCPCS) which is a set of procedure codes based on the CPT codes.
In addition, field 82 requires a physician identification code (rather than the physician's name), and fields 12-20 require patient name, gender and age, and date of service. There can also be fields for hospital affiliation, group practice, and other information. Thus, each medical claim form provides a wide range of information related to the provider's activities.
As the healthcare industry grows, the number of medical claims being submitted has increased tremendously. Because of the voluminous amount of medical claims being submitted daily from a large number of providers, many providers and payers have a difficult time managing the medical claims. As a result, clearinghouses have developed to assist payers and providers in dealing with the claim submission process. The clearinghouses receive medical claim forms from the providers, ensure that the forms are properly completed, and distribute the claim forms to the payers. The clearinghouses also distribute the status of submitted claim forms, such as rejected or accepted, from the payers to the providers. Recently, the processing of claim forms has been enhanced by electronic processing of these claim forms. Approximately 90% of all medical claim forms are processed electronically for payment. Electronic processing is further enhanced by use of standard format medical claim forms, such as those in the ANSI ASC X12N 837 Health Care Claims standard and the National Council for Prescription Drug Programs' Prescription Claim Transaction standard Version 5.1.
An exemplary system for providers to submit medical insurance claims to payers is illustrated in co-pending U.S. patent application Ser. No. 12/481,321, filed Jun. 9, 2009. The system includes providers, medical claim forms, clearinghouses, and payers. The providers submit the claim forms to the clearinghouses by paper or electronically as a file or other suitable format. The clearinghouses collect the claim forms from the providers, and distribute them to the payers. The providers can be physicians who provide diagnoses and treatment procedures for patients. The providers can be affiliated with private physician offices, hospitals, and other types of medical service facilities.
Many companies, such as pharmaceutical and medical device manufacturers and organizations related to medical service, have a great interest in promoting their products and services to specific groups of providers. To promote their products and services effectively, those companies want to target their products not to all providers, but to the most relevant group of providers in a specialized field. Thus, before promotion, a company would want a list of providers, such as physicians who performed particular diagnoses and procedures in the field of medicine that would most need the company's products. The providers on the list would be more likely than others to use or introduce the company's products to their patients. For instance, a manufacturer of a device for measuring blood sugar level may want a list of the top 100 physicians in the country that performed the highest number of diabetes diagnoses and treatments in the previous year. Those physicians are more likely than others to diagnose and treat diabetic patients in the near future and introduce the company's blood-level measuring device to their patients. Moreover, the manufacturer may want the list of the top 100 physicians to be sorted by the total number of diagnoses performed, or by gender and age range of the patients. Such a reporting list of physician activities would help the manufacturer to strategize business planning and maximize return on promotions.
Companies that offer reporting lists of provider activities generally obtain their information from the providers. However, the information from many providers is often summary data of the total number of diagnoses and treatments that the providers have performed. For instance, a hospital provides a summary for its many physicians. Those summaries typically do not provide breakdowns of how many diagnoses and treatments each physician affiliated with the hospital has performed. Thus, to estimate how many diagnoses or procedures each physician performed, the total number of services provided by the hospital is divided by the number of physicians. As a result of this crude apportioning approach, summary reports of physician activities do not accurately reflect the actual number of diagnoses and procedures that each physician actually performed.
However, with privacy concerns and laws limiting the ability of pharmaceutical companies to directly target service providers and patients, there is a need for a system and methods to generate reports of provider activities, derived from a database that includes information obtained from standardized and electronically processed medical claim data linked to each individual provider who performed the diagnoses and procedures, but with the information specifically identifying the individual provider or patient information encrypted to assure privacy and assure compliance with, e.g., HIPAA and all other applicable Federal and State laws and regulations.